Provider Demographics
NPI:1548515141
Name:TRAVIS PEDIATRIC THERAPY CENTER, PLLC
Entity type:Organization
Organization Name:TRAVIS PEDIATRIC THERAPY CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:409-861-1000
Mailing Address - Street 1:8117 GLADYS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-4000
Mailing Address - Country:US
Mailing Address - Phone:409-861-1000
Mailing Address - Fax:409-861-2241
Practice Address - Street 1:8117 GLADYS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-4000
Practice Address - Country:US
Practice Address - Phone:409-861-1000
Practice Address - Fax:409-861-2241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17454235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty